The Anatomy Of A Doctor Visit

Working as I do in an academic medical center, I’m frequently called upon to teach medical students. I do most of my teaching now with the third-year medical students when they rotate through our outpatient clinic. Usually, I’ll send them into an exam room on their own to see my patients (after requesting my patients’ permission to do so, which they nearly always grant) and then have them present the patient’s history to me in front of the patient. This model is efficient and accomplishes much: the medical students have the opportunity to sharpen their history-gathering and history-presenting skills, patients have the opportunity to clarify the history the students provide me as well as to make a contribution to the education of tomorrow’s doctors, I hear a (hopefully) concise and accurate story that I can pick through to arrive at accurate diagnoses of my patients’ problems, and I can evaluate and provide feedback on students’ clinical and personal skills having watched them in action.

I typically give a small talk to the medical students who rotate with me on the thought process I use in tackling patients’ problems in my clinic, and I thought readers might find it interesting to know how doctors (at least, this one) typically approach patient visits in an outpatient clinic.

IT’S ALL ABOUT AGENDAS

The moment I enter an exam room, before my patient even has a chance to speak, I’ve already started my assessment. This first part of the process happens quickly and is largely unconscious. In a flash I take in the picture I’m seeing: is my patient sitting comfortably reading a book or fidgeting in a strained posture? Does he stand to shake my hand when I enter the room or avoid all eye contact? What are his first words and how are they spoken? No right or wrong answers exist to these questions, and I’m careful to not infer too much from them. But I do always wonder about what the answers might imply: am I seeing anxiety, depression, impatience, anger? It matters a great deal which, if any, are present, both to the process of gathering a history and to the correct assessment of a patient’s problems.

Each and every time a patient comes to see me, I remind my medical students, they have an agenda and I have an agenda. (By “agenda” I mean simply a list of things we each want to discuss.) They may have only one thing they want to discuss or they may have twenty. Our agendas may overlap (I may also want to talk about their arthritis and cholesterol, for example) but often they’re quite distinct. (Obviously, I don’t yet know what new complaints they’ve brought with them.) What I do know patients bring with them in variably insignificant, small, and large quantities is anxiety—not only about what terrible malady I might end up telling them they have but also about being prevented from communicating their concerns. In today’s world, doctors tend to demonstrate non-verbally (and sometimes even verbally) their sense of urgency to be elsewhere. Many of us seem (and are) constantly distracted by the next thing we have to do, the end result often being that we’re not only half-listening to what our patients tell us but also are rushing through the visit, failing to ask clarifying questions that just might reveal the key to our patients’ problems.

To combat this problem, I deliberately spend a moment making small talk, deliberately slowing myself down and communicating by my action that I’m going to focus all my attention on my patients and listen to what they have to say. Then I frequently (though not always) do the following: I ask them to list for me everything they want to talk about, requesting that they avoid going into any detail as they do so. (That will come later, I reassure them.) After each item (“my ankle hurts”) I prompt them to continue by asking, “Anything else?” When they finally pause to consider if they have anything else left that concerns them and at last answer, “That’s about it…” I always respond, “Are you absolutely sure?” Usually they pause again, conduct a mental inventory or consult a list they’ve written out beforehand (something I heartily endorse), and tell me they’re done.

At this point, I’ve accomplished two important things (usually in under two minutes): I’ve learned the universe of their concerns and I’ve made them feel heard. When patients complain that their doctors rarely spend enough time with them what they’re really irritated by isn’t the time not spent but how little listening their provider seemed to do. In my experience, it’s possible to spend only five minutes with a patient (depending, of course, on the reason(s) they’ve come in) but still have them come away completely satisfied with the visit quality. (Accomplishing this feat in so little time isn’t the goal, of course, but the fact that it happens proves the point.)

Having heard and understood the full extent of a patient’s concerns, I’m now free to combine their agenda with mine and arrange them into one large list, prioritizing them using my clinical judgment according to their potential seriousness. Due to anxiety, for example, a patient may have mentioned “chest pain” as their last complaint, hoping whether consciously or unconsciously to downplay its significance. Luckily, because they weren’t given any time to go into detail before I gathered the entire list of their complaints, I can make their last complaint mentioned the first complaint discussed, ensuring I have enough time to gather those all-important details to the degree I require. If I’d failed to obtain an exhaustive list from them at the beginning, the complaint of chest pain might only surface at the end of the visit (something that used to happen to me all the time). I’d then be forced to spend an additional twenty minutes eliciting the details around this most important complaint, making me late for my next patient and preventing me from spending the appropriate amount of time and appropriate amount of focus on them.

Sometimes, of course, as I mentally glance over my combined list, I find no medically compelling reason to prioritize any one problem over another. In that case, I turn to the patient and ask them which complaints they want to discuss first.

IT’S ALL IN THE HISTORY

Once I’ve had my patient list their complaints, we start discussing the details of each. The medical history, I teach medical students, remains the most powerful diagnostic tool we have. Most students are skeptical of this for a long time, thinking diagnoses are mostly made with technology. Certainly, I acknowledge when they say this, technology has dramatically increased our ability to make many diagnoses. But with it has come an unintended consequence: an increased likelihood that providers will exhibit lazy thinking. Why bother to consider the diagnostic possibilities past a certain level of detail, after all, if you can simply order a test to get the right answer?

The reason, it turns out, is that if you apply technology with insufficient forethought, not only will you order a plethora of unnecessary tests on the way to the diagnosis, you may very well miss the diagnosis entirely. As just one example, consider pain—something that often has a functional cause rather than an anatomic cause, rendering the all-too-often mindlessly ordered CT scan useless. Unfortunately, I’ve lost count of the number of times I’ve had medical students suggest ordering abdominal CT scans without knowledge of a single qualifying detail of a patient’s abdominal pain. This thought error may be forgivable in medical students (it’s my job, after all, to train them), but I’ve seen many medical residents commit the same kind of error. I’ve come to believe it doesn’t happen just because ordering a CT scan is easier than thinking, or even that residents are terribly rushed (which they are), but rather because many newly minted doctors simply haven’t yet learned to trust the data the medical history offers them. It’s a trust that seems only to develop gradually with experience.

Nevertheless, each fact a health care provider gathers in the taking of a medical history is, in fact, a test itself. When I ask a 55-year-old man complaining of chest pain if he gets it with exertion and he says yes, in the right clinical setting that positive result carries as much prognostic value as a stress test. With each subsequent question, I adjust up or down the likelihood of the various diagnoses I’m considering until I arrive at a final “pretest” probability for each. The term “pretest” probability is used to indicate the probability of a disease being present that’s been calculated from the history alone, before more traditional tests are ordered. But it’s a misleading term in one sense because the testing has long since already begun—with the first question I asked.

Interestingly, the amazing advances in technology we’ve enjoyed in the last fifty years have added far more to our ability to treat than to diagnose. Which is why training medical students to take a thorough medical history will always remain relevant: no matter how much better our diagnostic tests become, we only know to order them in the first place because the history we gather first leads us to consider the diagnosis they’re able to make. Medicine, it turns out, isn’t a science at all, but rather the art of applying science to symptoms in such a way that yields us a diagnosis.

14 comments to The Anatomy Of A Doctor Visit

Why do you call a patient’s concerns “complaints”? To me complaints sounds like you think the patient is complaining—not voicing a concern or a worry.

ET: Excellent question. In medicine, “complaint” is the standard term used for a patient’s concern or worry. In the medical world it loses it’s pejorative connotation. I’m so used to using it I didn’t even think about that as an issue.

It is gratifying to see that there is one doctor (I have unfortunately not come across any one else such in recent times) who relies very much on his own diagnostic skills to decide on whether some elaborate technological test is in fact necessary or not, at a time when mindless prescription (I’ll endorse the pun, here) of unnecessary and costly technology-based testing has become the order of the day. Thanks for the post. It is my ardent hope that your proteges will emulate you to the full.

Oh man. Why aren’t you my doctor? You’re right; one of the biggest anxieties is that of not being heard. When I visit the doctor I usually have a “cheat sheet” (of symptoms, or relevant information, whatever) and try to be efficient, and my doctor is very friendly, but still…I feel the clock ticking from the moment I step into the room. It’s a kind of pressure that sometimes makes it hard to remember details or to give a good answer to a question.

Alex, how might we help our doctors hear our concerns? How can we put them at ease so they can focus on us? How can we encourage our doctors to look at our histories? To trust what we have to say to them?

Maxine: It can be difficult. Calling deliberate attention to your understanding of the process of history taking itself may prove useful in subtly reminding your provider of his or her most important job. Also, this post, When Doctors Don’t Know What’s Wrong, may help.

I like the approach of asking for a full list of concerns. I too often get caught by the ominous complaint on the way out the door. I’m going to give that a try! I have never really considered the level of anxiety related to being heard, probably a much higher level than I’ve realized. I don’t write notes during patient interviews. I think it is just another task that distract me from attending to the person in front of me.

Pregnant for the first time, I had my first visit with my OB. She examined me briefly, mentioned vitamins, walked to the door, and, with her hand on the door knob, turned and said, “Any questions?” I told her, yes, I had a list, and I’d like to put my clothes on and discuss them with her. I changed to a practice with nurse midwives before my next visit. In my experience, most MDs, at least mentally, keep one hand on the door knob.

The main mistake a doctor can make is to interrupt a patient before he’s finished explaining the symptoms/reason for his visit. Giving a patient the wrong diagnosis because you didn’t listen well is a waste of everyone’s time. Fortunately for your patients, you seem very thorough, but in my experience you’re the exception…

p.s.—I wanted to ask you, what is your advice to patients when the doctor’s agenda is majorly dominating the visit to the point that the patient is concerned over the course of the visit that his needs aren’t being met? In the long term, maybe you just don’t go back to that doctor, but in the short term your reason for making the appointment (such as an acute illness or injury) is getting brushed aside.

Thanks

Mira: In the short term, I think drawing the doctor’s attention to the fact that the patient’s main concern is being brushed aside is your best bet. This presumes the doctor is unconscious of his or her failing to listen. If a doctor doesn’t respond to that, probably not much more to do than find another one.

Assumption: that the doctor knows more about the patient’s “complaint” than the patient knows. This is nearly always wrong. The patient knows him/herself well. The “complaint” has evolved, usually gradually over time, which gives the patient time to get in touch with his/her signs/symptoms. Thus, the patient has “experience” with him/herself—which makes the patient the expert, IMHO.

On the other hand, the doctor knows medicine/diagnosis/prognosis in a general way, and must adapt his knowledge to this individual patient. Will the doctor be successful in going from the general to the particular?

Assumption: that whatever the diagnosis turns out to be, there will be a pill or a treatment offered to deal with the complaint. Yes, it will be offered. But will it really “cure” the problem? How much can the patient do by him/herself to address the complaint? Has the patient done everything in his/her power to address the complaint? Does the patient want an easy answer or guarantees from the doc? (Doc, tell the patient that is NOT a happenin’ thing.)

Nurses make assessments in different ways. Nurses have an entirely different perspective. A nurse isn’t aiming at a diagnosis/prognosis—that is up to the medical doctor. A nurse assesses a patient in these areas:

1) stability—is this patient acutely ill or emergent? Or is this a “complaint” that has developed gradually or is a chronic complaint/condition? Vital signs, including discomfort/pain (as the 5th vital sign) are rather concrete and objective signs of stability.

2) adaptation—nurses find out how the patient is dealing with his/her problem/complaint. Coping strategies that the patient has. Emotional and spiritual adaptation. Healthy lifestyle to counteract, in some cases. Changes in diet, if indicated. Sometimes, stages of grief over lost abilities, loss of adaptability, effects on others, effects on work life. (A nursing care plan is then developed to meet the various needs of the patient re: adaptation, emotional distress, grief, nutritional deficits, knowledge deficits, etc.)

A patient’s transparency with the nurse is legend. Nurses are at the top of the list of “the most trusted” professionals. If you are a nurse (as I am), you cannot help but listen, because patients want to talk to the nurse who they see so often—many times/day, if they are hospitalized. A nurse learns to read body language—it is developed to a high art, I’d say. So there are objective numbers—vital signs, lab values, pain scale—but there is also “guarding” a painful area on their body; there are facial expressions, involuntary movements, posture, etc. The nurse is trained to pay attention to these things, which add up to 80% of all communications.

Everyone wants to be whole; to be healed; to become better. We look to medical people to acknowledge this need; and to support the striving that we all experience. As Alex asserts, this is more art than science.

For my part, if I am the patient, I rarely want a(nother) pill. (Exception—sometimes pain can be best addressed with a pill. You have to take complaints of pain very seriously.) I want validation, support, encouragement to carry on with my adaptation. If I say “No, thanks” to the proffered pill, I don’t want to see surprise, or worse, impatience or contempt on the doc’s face. Though I have come to you as a supplicant (or so it feels to me), I want to be treated with respect and maintain my dignity—even if I am half-naked on the examining table.

This is an interesting post (though actually, I learn from all of them!). As someone who moves a lot, I’ve had many different doctors over the past 10 years. Most recently, I went to a new doctor in my current community for a complaint that had been treated successfully by a previous doctor with a certain prescription. When I mentioned this, the new doctor “overruled” me and three weeks later, having now tried two new prescriptions, my issue has not improved at all. I’ve become quite hurt and angry that my own experience was so quickly dismissed, but also bewildered that I felt I didn’t have the credibility to stand up for my version of my experience, given the doctor’s somewhat patronizing approach to me! I think the approaches you are teaching will make practitioners receptive to (being open to) learning from patients, too…

Tess: Unfortunately, you’re far from the first patient who I’ve heard has had this experience. Doctors definitely need to listen better…

As an aspiring premed student, I wholeheartedly agree with your technique and hope to someday put it into practice myself. I have always thought that an excellent doctor isn’t just someone who knows a lot about medicine, but someone who also knows a lot about the art of human interaction. Listening, with undivided attention, and subsequently asking pertinent questions are some of the most powerful diagnostic tools a physician can have in his/her arsenal.

Wow, I wish you were my doctor! This article was really helpful for me. I often have more than one concern when I go to the doctor but didn’t know if this was okay. I feel like I might be taking up too much time and maybe I’m supposed to have multiple visits. I’m glad to know this is okay and that it’s okay to bring a list. I’ve wanted to do that but was embarassed and often end up forgetting to ask about things because of it. This article has given me a lot more confidence to be more assertive with my doctor and feel less concerned about imposing on his busy schedule.

The reality is “a lot” of doctors plow through patients day to day. While they do care about the needs and concerns of their patients, I feel they are more interested in seeing a volume of patients. I guess now all you need to understand is how doctors really think! I found this and thought it was appropriate for this article!